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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> a 3° <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLEn PERMIT CALL 209 953--76197 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> n <br /> JOB ADDRESS yI/ .1 1 G-fOVC [d' CITY/Zip TNo►rv/�/ 95'68& y <br /> CROSS STREET Z - 5' APN 00/- VG o-&2- / PARCEL SIZE aC-' e <br /> OWNER NAME rDhY MOORZ PHONE <br /> OWNER ADDRESS I/17�9 <br /> e33 w - WL••INV� �I"D�'L ��C CITYI$TATEIZIP /f'IOI-IDN <br /> CONTRACTOR A,QA•V� P4"!FO _ PHONE 9 <br /> CONTRACTOR ADDRESS 32 7 qt '/- CITYI$TATEIZIP rPf /'1 •� <br /> LICENSE ❑C42 C-36 OTHER NUMBER 1 I EXPIRATION DATE <br /> ATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: CDOTdinai¢6 X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# _ <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY Bal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY Bal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME R <br /> ❑ LIFT STATION SIZE TvPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES <br /> q� LENGTH OF LINES <br /> 00 ft G4 <br /> DISTANCE TO NEAREST WELL /00 t ft FOUNDATION .Z4 R PROPERTYLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft n <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft A <br /> !`J MOUNDED WIDTH R LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft QI <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LME ft <- <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY I <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. L� <br /> /M1/�,1,N/IMUM i4 OUR ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 b (. <br /> SIGNED Cr1i� TITLE v :JO� DATE /- /O-0s <br />